Kathy Hassey understands not everyone appreciates the range of responsibilities she holds as health services coordinator for the Hudson Public Schools, but she is still surprised when other health professionals dismiss the importance of her work.

Earlier this year, she accompanied her teenage son to the emergency room at a local hospital.

"'You're a school nurse?'" she said the ER technician assigned to their case asked. "'What do you do, give out aspirin and scoot the kids back to class?'"

Hassey responded with carefully controlled patience: "Well, sometimes I have to suction their tracheostomy tubes before sending them back to class."

Few school nurses will be surprised by that story, although they generally try not to take offense. After all, until about 10 years ago, school nursing was often seen as a fairly undemanding job.

Most adults now old enough to have school-age children remember going to the infirmary every few months for a playground bruise or stomach ache, undergoing annual hearing and vision screenings, and an appearance by the school nurse in science class at some point during junior high to show a movie about puberty.

These days, the average health office in a large elementary school can see as many as 50 student visits a day, but what has changed most about the profession in recent decades is not so much the number of sick children as the myriad health issues that affect them.

"Diabetes, asthma, muscular dystrophy, depression, hypertension, eating disorders, epilepsy," reels off Betty Irelan, nursing coordinator for the Groton-Dunstable school system. Irelan has been a school nurse for the past 25 years and has witnessed firsthand the changes in her job requirements.

Irelan explains there are two significant reasons the medical issues present in school populations have changed so dramatically in recent years.

" In the past five to 10 years, medical technology has made it possible to save babies born with congenital health problems who at one time would not have survived," she says. "Right now, many of those same kids are entering the school system. Also, what schools call 'inclusion' means that kids with physical or emotional issues that once would have required them to attend special schools are now being mainstreamed into the public schools. That puts additional responsibilities on us as well."

Anne Sheetz says school nursing is "one of the most exciting and rapidly changing specialty areas in health care today."

Since 1990, Sheetz has served as the director of school health services for the state Department of Public Health, and many school nurses credit her with the sea change the profession seems to have undergone in recent years.

Funding that Sheetz has secured covers interests as diverse as increasing the number of school nurses available to a school system, providing comprehensive computerization systems for nursing offices and fostering outreach efforts toward disease prevention. It used to be that some school nurses had only an associate's degree, but now state regulations require at least a bachelor of science in nursing.

And a school nurse has to be ready for anything, Kathy Hassey of the Hudson schools points out.

"You're professionally isolated. You might be the one medical professional in a building with 400 kids. In a hospital setting, you'd probably have eight other nurses on the floor with you, a doctor at your beck and call, and every piece of equipment you might need on hand. In the school office, you're really on your own."

Another health issue in schools today is students with life-threatening allergies to bee stings, Latex or certain foods.

Kathy Horan, director of nursing in the Carlisle Public Schools, says her office stocks EpiPens for 40 students, compared with two when she entered the field 12 years ago. The prevalence of serious allergies means more than just the need for medical treatment, she says; it requires additional education campus-wide.

Horan runs yearly training teachers and school staff members, from cafeteria workers to bus drivers, so any employee of her school can recognize and deal with an allergic reaction.

Horan is like many school nurses for whom daily on-the-job requirements extend beyond direct clinical oversight. She meets regularly with students in classroom settings for everything from a discussion on hand-washing with first-graders to CPR training for middle schoolers.

Her school system hired an additional nurse to cover the office so that Horan could fulfill her many nonclinical responsibilities, which include meeting weekly with administrators and guidance counselors to review the cases of any students for whom particular concern is warranted. That might mean anything from a recent death or serious illness affecting the child's family to evidence of possible drug abuse.

Gail Kelley, nursing director for the Dedham Public Schools, points out that school nurses sometimes have to fill the roles that should be held by pediatricians.

"Unfortunately, there are children without medical insurance," she says. "So in some situations, you are the only health professional a child is going to see. Furthermore, even if a child has a pediatrician, sometimes other obstacles, such as transportation, might keep them from getting to the doctor when they need to go. That's why school nurses have to have such sharp assessment skills. We have to remain absolutely up-to-date regarding clinical knowledge, first aid, emergency aid. We never know what will be required of us on any given day."

Betty Irelan of Groton-Dunstable often finds herself helping parents interpret information their pediatrician has given them.

"Parents sometimes leave the pediatrician's office without fully understanding a medication that their child has been prescribed," she cites as an example. If a parent comes to her with questions, she can help augment the explanation that the pediatrician has given.

"This job is so much more demanding than it was when I started in 1980, but it's also a lot more interesting," says Irelan. "Fortunately, parents and administrators are usually very supportive of our work."

Joan Hoffman, an elementary school nurse at the Thorpe School in Danvers, extends her educational outreach efforts to parents by sending home a monthly newsletter apprising them of seasonal concerns such as flu or Lyme disease.

"Parents should use their school nurses as a resource," she says. "Along with actually providing care to the kids, we can give them information on specialists, support groups, whatever they need."

"The best part of the job? That's easy," says Hoffman. "Those little faces that come in crying and leave smiling."
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